Extent of surgery and survival in early lung carcinoma : Implications for overdiagnosis in Stage IA nonsmall cell lung carcinoma

With the advent of minimally invasive surgical techniques, a determination of the efficacy of limited resection in Stage IA nonsmall cell lung carcinoma (NSCLC) must be determined. The critical question is whether the probability of cure is equivalent with limited resection and with standard lobectomy. The results of three independent reports are analyzed. The only randomized trial is that of the Lung Cancer Study Group, in which 247 patients with peripheral Stage IA lesions were randomized to lobectomy or limited resection. The results indicate that recurrence rate and lung carcinoma mortality rates are higher among those undergoing limited resection. In another nonrandomized series, which involved 218 consecutive Stage IA patients, there was a significantly inferior survival rates among those undergoing limited resection compared with lobectomy. The third study is a retrospective analysis involving 244 Stage I patients treated at the Brigham and Women's Hospital (BWH). This trial shows that limited resection is inferior to anatomic resection in both Stage IA and Stage IB NSCLC. Indeed, the importance of complete resection is underscored by the finding that Stage IA patients undergoing limited resection were significantly less likely to be cured that Stage IB patients undergoing lobectomy. Accordingly, the BWH trial supports the conclusion that the extent of surgical resection is more powerful determinant of survival than natural history of disease in Stage I NSCLC. Cumulatively, the results of these three trials show that among patients with Stage I NSCLC, limited resection is inferior to lobectomy with regard to the probability of producing cure. The finding that limited resection is inferior to lobectomy has relevance to the hypothesis that chest X-ray screening may lead to the identification of clinically unimportant lung carcinomas, which have been termed pseudotumors. This hypothesis, known as overdiagnosis, is the only alternative to the conclusion from four existing randomized trials that chest X-ray screening leads to an improvement in lung cancer cure rates. However, if extent of surgical resection is the major determinant of survival in Stage IA NSCLC, then these lesions must be clinically important. These findings support the conclusion that chest X-ray screening does not lead to the detection of Stage IA pseudotumors of the lung. Accordingly, current public policy calling for no routine screening for the early detection of lung cancer must be